C 3, 4 and 5, keep the diaphragm alive

Intensive Care Med (2006) 32:11091111

DOI 10.1007/s00134-006-0209-3 EDITORIALRobert I. Ross Russell C 3, 4 and 5, keep the diaphragm aliveReceived: 26 April 2006Accepted: 26 April 2006Published online: 2 June 2006

Springer-Verlag 2006This editorial refers to the articles available at:

http://dx.doi.org/10.1007/s00134-006-0207-5 and

http://dx.doi.org/10.1007/s00134-006-0208-4R. I. Ross Russell ()Addenbrookes Hospital, Department of Paediatrics,

Hills Road, CB2 2QQ Cambridge, UKe-mail: [email protected]

Tel.: [phone]In Intensive Care Medicine Lemmer et al. [1] now look at

phrenic nerve damage (PND) in children undergoing cardiac surgery and at the value of diaphragmatic plication in

shortening the post-operative course of such patients [1].

This technique has been well described previously [1, 2, 3,

4, 5, 6, 7, 8], but the authors both provide further evidence

for its efficacy and emphasise the particular problems seen

in infants with PND. Hospital stay, duration of ventilation

and antibiotic use were all increased in patients with PND,

and plication of the affected hemidiaphragm was undertaken in 54% of that patient group, including two patients

with bilateral injury.This surgical approach is countered in the contribution

by Dagan et al. [2]. They focus on the management of

the small group of patients who develop bilateral PND

and discuss their experience of taking a conservative

line. They report nine patients, all of whom recovered

and came off ventilation over 29 weeks. None were

given tracheotomies, although three patients did receive

unilateral plication. They argue coherently that bilateral

plication is of little value and that recovery occurs reasonably fast. However, bilateral PND is relatively uncommon

and estimates of its frequency are difficult to find, but are

probably between 4 and 10% of PNDs, or about 0.10.6%

of cardiac operations in adults [9, 10, 11]. Four paediatric

cases of bilateral PND following mustard procedures were

reported by Stewart et al. [12] in 1986, and other reports

have included a small number of children with bilateral

damage [9, 13, 14, 15].Given that plication of the affected diaphragm has long

been recognised as an effective treatment for unilateral

PND [3, 4, 5, 6, 7, 8, 13, 16], it becomes appropriate to

look at the historical context of PND after cardiac surgery,

as the identification of those patients who have PND is not

completely clear, and selection for surgery can therefore

be difficult. PND as a...